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APPLICATION FOR PERMIT r tJ r" {• /�f�r? SAN JOAQUIN LOCAL HEALTH DISTRICT ( 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' Job Address _>['� _`� �n _sYp,�,,jg, (-cL City �1U4 r Lot Size �_ .z`f�r�r� PM __ I Owner's Name ��' - y (t)0 Address _s-n n� G ��ittS�/��;,to �; i��/ Phone 'ti ) /1 Contsactor1/99 c � r Addsess r^l�• �.��/5� y� �f1/� License No��a't%3 Phone �<<'J/--a TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Q DESTRUCTION ❑ PUMP,INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK `][}'i- SEWER LINES DISPOSAL FLDI )PROP. LINE _( f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ ,t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S �� ! ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingfZ3!SFe1:_/ Specifications [7 Public ( Other 171 Delta Depth of Grout Seal } Type f GroutJit C -T7_t d r - I I Irrigation c3l-�_ZlApprox. Depth J I Eastern Surface Seal installed by [ Y'x/ +~} r ✓tiK,} Repair Work Done ❑' Type of Pump H.P. -12 State Work Done --.-,. 0 Well Destruction ❑ Well Diameter Sealing Material (top 50') w Depth Filler Material (Below 50') _ 1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I f DESTRUCTION I I INo septic system permitted if public sewer is Jl available within 200 feetA Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Vy Distance to nearest: Well Foundation Property Line LEACHING LINE ❑. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California." The applicant mus call for all required inspections. Cortrplete drawing on reverse side. Signed XTitle: Date: _r /F, 9 J OR DE A MENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lo 1 369.3621 ❑ Nfanteca 823-7104 ❑ Tracy 835-6385 i Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 1 INFO `AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ;;DATE PERMIT NO. +.Eli I3-24(REV.i/x 51 /�si EH 14-2e f�/ el:s-5` ` 6 J ( l 1�_17G -S'S-7